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Letters to the Editor REFERENCES 1. Fassett RG, Robertson IK, Mace R, Youl L, Challenor S, Bull R. Palliative care in end-stage kidney disease. Nephrology (Carlton) 2011;16:4–12. 2. Quill TE, Holloway RG. Evidence, preferences, recommendations–finding the right balance in patient care. N Engl J Med 2012;366:1653–5. 3. Thavarajah N, Wong K, Zhang L et al. Continued success in providing timely palliative radiation therapy at the Rapid Response Radiotherapy Program: a review of 2008–2012. Curr Oncol 2013;20:e206–11. 4. Moss AH. Shared decision-making in dialysis: the new RPA/ ASN guideline on appropriate initiation and withdrawal of treatment. Am J Kidney Dis 2001;37:1081–91.
Vascular Access Puncture Under Ultrasound Guidance Dear Editor, Hemodialysis therapy cannot be initiated without needle placement for vascular access. However, changes in epidemiology of a hemodialysis patient can make the access puncture very difficult (1). To ensure safe and secure treatments, accurate needle placement for vascular access is required. Puncture under ultrasonography (US) has been proven to reduce complications and to improve success rates during central vein puncture (2,3). We developed an US-guided vascular access puncture method (4) and found it to be a very useful method, especially in cases of where access is difficult. In the present letter, we explain the detailed methods of the procedure. DETAILED METHODS OF ACCESS CANNULATION UNDER US GUIDANCE 1. Examine the direction and route of the target blood vessel in a longitudinal view (Fig. 1A). 2. Place the probe perpendicular to the vessel. The orientation of the probe (left to right) is made the same as on the screen, which makes the correction of needle direction easier if the needle is misplaced (Fig. 1B). 3. The probe center is placed just above the center of the vessel with the use of the mark and guide on the probe and on the screen, respectively. 4. The distance from the probe to the puncture point is crucial so that the needle appears in the very center of the vessel on the screen when the needle makes the puncture. The distance (l) from the probe to the puncture point can be expressed as l = d/tanθ (where θ is the needle angle, and d is the depth of the center of the vessel) (Fig. 1C). For © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
213
example, when we thrust the needle at an angle of 30 degrees and the center of the vessel is located 7 mm beneath the skin surface, we should puncture the needle at 12 mm (=7/tan(30°)) before the probe. 5. Note the difference of the appearance between the needle tip and the needle shaft (the echo of the shaft has an eminent acoustic shadow as Kamata et al. describe [5]). To confirm that the needle is placed within the vessel, the probe is thrust little by little in accordance with the movement of the needle tip, with the exact tip of the needle on the screen, after appearance of the needle tip (we named this the “looper method”) (Fig. 1D,E). 6. After placing the needle, proper placement of the needle is confirmed in longitudinal view (Fig. 1F). 7. When the needle is located entirely within the vessel, the needle can be moved freely without tagging the wall of the blood vessel (we also named this the “free-moving sign”). Otherwise, the needle moves together with the wall of the blood vessel. Thereafter, thrusting the cannula completes the puncture (Fig. 1G).
CONSIDERATIONS Modification similar to that which appears on the screen will correct the needle direction when the needle is located outside of the target vessel. For example, when the needle tip appears at the left side of the target vessel, one can modify the direction of the needle to the right. We sometimes lose the tip on the screen. On such occasions, we can identify the needle shaft as a high echo with an eminent acoustic shadow at the puncture site. Thereafter we move the probe carefully to the direction of the needle tip; we can usually identify the tip. At the tip, the needle echo will disappear further when moving the probe forward. Afterward some modification should be undertaken as described above. We used a transverse view in the current technique. A previous study explained one shortcoming of the transverse view (6) as the possibility of depth underestimation. However, we overcome this disadvantage by moving the probe properly while thrusting the needle to view the very tip of the needle in the center of the vessel in the transverse view. In conclusion, this is the first report providing a detailed explanation of vascular access puncture under US guidance. We believe in its importance and do hope that the present method will help widen the
Ther Apher Dial, Vol. 18, No. 2, 2014
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Letters to the Editor FIG. 1. Detailed appearance of access puncture under ultrasound (US) guidance. (A) Place the probe parallel to the target blood vessel. Find the suitable puncture site, where the blood vessel is straight enough. (B) Place the probe in rectangular position to the vessel. The direction of the probe (left and right) is made the same as what appears on the screen, so that it is easier to correct the direction of the needle if it has been misplaced. (C) Puncture the skin at the point previously determined. The distance from the probe is critical. (D) The tip of the needle will appear on the screen when the puncture is successful. (E) Thrust the needle little by little with chasing its tip with the probe. We named this method as the “looper method”. (F) After placing the needle, confirm the proper placement under longitudinal view. (G) When the needle is successfully placed in the vessel, the tip of the needle can be moved freely without tagging the wall of the blood vessel on the screen (we also named this the “free-moving sign”).
◀ d l
θ
use of AVF and provide improvement in patient safety and satisfaction. Acknowledgment: NH received a Scholarship Fund Donation from Coviden Japan (Tokyo, Japan), a provider of hand-held US devices, for an unspecified purpose.
Norio Hanafusa,1,2 Eisei Noiri,1 and Masaomi Nangaku1 1 Department of Hemodialysis and Apheresis and 2 Division of Total Renal Care Medicine, the University of Tokyo Hospital, Tokyo, Japan Email: [email protected] REFERENCES 1. Kerlan RK Jr, LaBerge JM. Fistula first, stent graft second. N Engl J Med 2010;362:550–2. 2. Hind D, Calvert N, McWilliams R et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361–4. 3. Randolph AG, Cook DJ, Gonzales CA et al. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053–8. 4. Hanafusa N, Kondo Y, Kaneko T et al. Vascular access puncture method with guidance by a portable ultrasonographic device. J Jpn Soc Dial Ther 2007;40:517–21. (in Japanese) 5. Kamata T, Ochiai M, Osaki K et al. Ultrasound-guided brachial venous cannulation as a novel venous needle site in hemodialysis patients. J Jpn Soc Dial Ther 2011;44:237–43. (in Japanese) 6. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364:749–57.
Adiponectin Levels in Hemodialysis Patients Dear Editor, We read the article “Plasma Adiponectin Levels for Prediction of Cardiovascular Risk Among There is no conflict of interests.
Ther Apher Dial, Vol. 18, No. 2, 2014
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
Letters to the Editor REFERENCES 1. Fassett RG, Robertson IK, Mace R, Youl L, Challenor S, Bull R. Palliative care in end-stage kidney disease. Nephrology (Carlton) 2011;16:4–12. 2. Quill TE, Holloway RG. Evidence, preferences, recommendations–finding the right balance in patient care. N Engl J Med 2012;366:1653–5. 3. Thavarajah N, Wong K, Zhang L et al. Continued success in providing timely palliative radiation therapy at the Rapid Response Radiotherapy Program: a review of 2008–2012. Curr Oncol 2013;20:e206–11. 4. Moss AH. Shared decision-making in dialysis: the new RPA/ ASN guideline on appropriate initiation and withdrawal of treatment. Am J Kidney Dis 2001;37:1081–91.
Vascular Access Puncture Under Ultrasound Guidance Dear Editor, Hemodialysis therapy cannot be initiated without needle placement for vascular access. However, changes in epidemiology of a hemodialysis patient can make the access puncture very difficult (1). To ensure safe and secure treatments, accurate needle placement for vascular access is required. Puncture under ultrasonography (US) has been proven to reduce complications and to improve success rates during central vein puncture (2,3). We developed an US-guided vascular access puncture method (4) and found it to be a very useful method, especially in cases of where access is difficult. In the present letter, we explain the detailed methods of the procedure. DETAILED METHODS OF ACCESS CANNULATION UNDER US GUIDANCE 1. Examine the direction and route of the target blood vessel in a longitudinal view (Fig. 1A). 2. Place the probe perpendicular to the vessel. The orientation of the probe (left to right) is made the same as on the screen, which makes the correction of needle direction easier if the needle is misplaced (Fig. 1B). 3. The probe center is placed just above the center of the vessel with the use of the mark and guide on the probe and on the screen, respectively. 4. The distance from the probe to the puncture point is crucial so that the needle appears in the very center of the vessel on the screen when the needle makes the puncture. The distance (l) from the probe to the puncture point can be expressed as l = d/tanθ (where θ is the needle angle, and d is the depth of the center of the vessel) (Fig. 1C). For © 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
213
example, when we thrust the needle at an angle of 30 degrees and the center of the vessel is located 7 mm beneath the skin surface, we should puncture the needle at 12 mm (=7/tan(30°)) before the probe. 5. Note the difference of the appearance between the needle tip and the needle shaft (the echo of the shaft has an eminent acoustic shadow as Kamata et al. describe [5]). To confirm that the needle is placed within the vessel, the probe is thrust little by little in accordance with the movement of the needle tip, with the exact tip of the needle on the screen, after appearance of the needle tip (we named this the “looper method”) (Fig. 1D,E). 6. After placing the needle, proper placement of the needle is confirmed in longitudinal view (Fig. 1F). 7. When the needle is located entirely within the vessel, the needle can be moved freely without tagging the wall of the blood vessel (we also named this the “free-moving sign”). Otherwise, the needle moves together with the wall of the blood vessel. Thereafter, thrusting the cannula completes the puncture (Fig. 1G).
CONSIDERATIONS Modification similar to that which appears on the screen will correct the needle direction when the needle is located outside of the target vessel. For example, when the needle tip appears at the left side of the target vessel, one can modify the direction of the needle to the right. We sometimes lose the tip on the screen. On such occasions, we can identify the needle shaft as a high echo with an eminent acoustic shadow at the puncture site. Thereafter we move the probe carefully to the direction of the needle tip; we can usually identify the tip. At the tip, the needle echo will disappear further when moving the probe forward. Afterward some modification should be undertaken as described above. We used a transverse view in the current technique. A previous study explained one shortcoming of the transverse view (6) as the possibility of depth underestimation. However, we overcome this disadvantage by moving the probe properly while thrusting the needle to view the very tip of the needle in the center of the vessel in the transverse view. In conclusion, this is the first report providing a detailed explanation of vascular access puncture under US guidance. We believe in its importance and do hope that the present method will help widen the
Ther Apher Dial, Vol. 18, No. 2, 2014
bs_bs_banner
214
Letters to the Editor FIG. 1. Detailed appearance of access puncture under ultrasound (US) guidance. (A) Place the probe parallel to the target blood vessel. Find the suitable puncture site, where the blood vessel is straight enough. (B) Place the probe in rectangular position to the vessel. The direction of the probe (left and right) is made the same as what appears on the screen, so that it is easier to correct the direction of the needle if it has been misplaced. (C) Puncture the skin at the point previously determined. The distance from the probe is critical. (D) The tip of the needle will appear on the screen when the puncture is successful. (E) Thrust the needle little by little with chasing its tip with the probe. We named this method as the “looper method”. (F) After placing the needle, confirm the proper placement under longitudinal view. (G) When the needle is successfully placed in the vessel, the tip of the needle can be moved freely without tagging the wall of the blood vessel on the screen (we also named this the “free-moving sign”).
◀ d l
θ
use of AVF and provide improvement in patient safety and satisfaction. Acknowledgment: NH received a Scholarship Fund Donation from Coviden Japan (Tokyo, Japan), a provider of hand-held US devices, for an unspecified purpose.
Norio Hanafusa,1,2 Eisei Noiri,1 and Masaomi Nangaku1 1 Department of Hemodialysis and Apheresis and 2 Division of Total Renal Care Medicine, the University of Tokyo Hospital, Tokyo, Japan Email: [email protected] REFERENCES 1. Kerlan RK Jr, LaBerge JM. Fistula first, stent graft second. N Engl J Med 2010;362:550–2. 2. Hind D, Calvert N, McWilliams R et al. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361–4. 3. Randolph AG, Cook DJ, Gonzales CA et al. Ultrasound guidance for placement of central venous catheters: a meta-analysis of the literature. Crit Care Med 1996;24:2053–8. 4. Hanafusa N, Kondo Y, Kaneko T et al. Vascular access puncture method with guidance by a portable ultrasonographic device. J Jpn Soc Dial Ther 2007;40:517–21. (in Japanese) 5. Kamata T, Ochiai M, Osaki K et al. Ultrasound-guided brachial venous cannulation as a novel venous needle site in hemodialysis patients. J Jpn Soc Dial Ther 2011;44:237–43. (in Japanese) 6. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364:749–57.
Adiponectin Levels in Hemodialysis Patients Dear Editor, We read the article “Plasma Adiponectin Levels for Prediction of Cardiovascular Risk Among There is no conflict of interests.
Ther Apher Dial, Vol. 18, No. 2, 2014
© 2014 The Authors Therapeutic Apheresis and Dialysis © 2014 International Society for Apheresis
